The long-awaited review by health executive Sheila Weatherill detailed a catalogue of errors and gaps in the country’s food safety network that all contributed to the deaths of 22 people. She concluded that while listeria is difficult to detect, “more could have been done to prevent it happening in the first place and…more must be done to make sure it doesn’t happen again.”
“In all likelihood, none of the individual elements that contributed to the outbreak was sufficient to have caused it alone, so each part of the food safety system must work together as perfectly as possible,” she said quoting one expert adviser. “And what we found is that our food safety system did not work as perfectly as it need to.”
The report, six months in the making, identified a slew of problems with Maple Leaf’s procedures, federal regulations and a slow and disjointed response from the fragmented, understaffed and disorganised food safety bodies.
Company errors and regulatory faults
Maple Leaf, whose deli-meats were responsible for the contamination, thought the listeria problems detected at its Toronto plant in 2007 and 2008 were under control and failed to follow its own listeria policy, said the report. A communication breakdown between plant staff and head office meant the problem was never tackled, despite repeated instances of the deadly bug being detected at the facility.
The company didn’t initially report “repeated occurrences of listeria” because they were not required to do so under federal law, said Weatherill. The government later said this was now obligatory. The Compliance Verification System developed by the Canadian Food Inspection Agency (CFIA) was highlighted as needing “critical improvements” as it did not require inspectors to ask for or examine listeria tests carried out by companies. A shortage of inspectors was also identified.
The listeria policy of Health Canada was criticised as being too loose by failing to “provide adequate direction on expected outcomes leaving room for industry interpretation”. Its lack of integration with GFIA policies led to “gaps and overlaps”.
Senior officials in Ontario, who were initially responsible for dealing with the outbreak, took three weeks to realize the seriousness of the issue, leading to what was called a “void in leadership in managing the crisis”. There was no clear understanding of what the role of each department was, meaning the response was characterized by “inconsistent management”.
Lack of urgency
The report pin-pointed a lack of urgency to the outbreak as a major problem, including Maple Leaf’s failure to raise the alarm or provide product distribution records. The country’s Public Health Agency delayed in identifying the situation as a public health emergency because “it did not consider it had the federal leadership role”. Health Canada’s Health Risk Assessment Team was not working on a 24/7 basis in summer 2008 which left “gaps in the coverage” during the response.
Consumers were left in the dark with information from governments and health bodies failing “to provide the public with what they needed” said the report. Federal communications were “slow off the mark” and ceased too quickly, added the inquiry.
There was a perceived lack of federal leadership and a conflict of interest from the politician leading on the issue given that he was responsible for both the Ministry of Agriculture and the CFIA.
Weatherill made 57 recommendations to the federal government. Among them were:
* Improved training for food inspectors
* Giving Canada's public health agency the lead role in responding to national food-borne emergencies
* Ordering an external audit to look at whether more inspectors are needed
* Boosting monitoring of some production plants and products based on higher risk.
Agriculture and Agri-Food Minister Gerry Ritz did not say if his government would implement all the recommendations, but said it would use them as "part of a guideline" to strengthen the food-safety system. He added the government has already carried out some recommendations, such as making listeria testing and reporting by food companies mandatory and hiring more inspectors.
"There is no perfect answer (to preventing an outbreak), no one to stand up and say, 'I did it.' Everyone takes responsibility for their portion of it," said Ritz.
A copy of the full report can be found via the following link: http://www.listeriosis-listeriose.investigation-enquete.gc.ca/lirs_rpt_e.pdf